Fear and safe sex on the decline

George F. Will, Washington Post Writers Group

Published 4:00 am, Sunday, June 9, 2002

With AIDS, progress has perils, as Mitchell Katz knows. No city is more preoccupied with AIDS than San Francisco, and Katz, the director of health, has the challenge of matching his AIDS message to the moment.

A 42-year-old Brooklyn-born graduate of Harvard Medical School who moved here in 1986 so he could work on AIDS cases, Katz is gay and a new father, having recently returned from Ho Chi Minh City with 4-month-old Maxwell, who this day is in repose in a stroller in Katz's office, next to Katz's bicycle. A very San Francisco tableau.

This city also has a distinctive problem regarding AIDS. In an epidemic, the primary public health task is to protect the uninfected. However, that is becoming harder here because of gay men's confidence in the ability of new drugs -- protease inhibitors, which began to be available in 1996 -- to enable HIV-positive people to lead normal, and longer, lives.

Sex, says Katz, is a powerful motivator, but so is fear. Fifteen years ago "to have unsafe sex was to die." So "people always negotiated safe sex." The inhibitors do not work for everyone and often have unpleasant side effects -- nausea, diarrhea. But those do not cause fear of HIV the way a frequent sight on San Francisco streets did a decade ago -- the sight of a young, emaciated man with a cane, obviously dying.

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Katz says that San Franciscans still dying of AIDS were given anti- retroviral medications one at a time, before today's combinations were available. Now, says Katz, gay men who are frequently in settings involving unsafe sex "say to themselves, 'So, now I'm going to have to take medicine. I'm 35 and I'll live to 65 instead of 75.' "

Worldwide, 16,000 persons are infected with HIV daily, most by heterosexual contact. More than 40 million persons are living with HIV, two-thirds of them in sub-Sahara Africa, where AIDS kills many times more people annually than do all the continent's wars. AIDS is the world's fourth-biggest killer, but HIV's complex biology has frustrated the quest for a vaccine.

The Salk vaccine that defeated polio gave Americans a misleading paradigm of how progress is made in public health. AIDS can be largely contained in America by avoidance of risky behavior by two groups. Two-thirds of new infections result from sexual contacts between gay men and the sharing of needles by intravenous drug users.

Katz says that one reason no baby has been born with HIV in San Francisco in more than two years is that the city has distributed 2 million clean needles to drug users. But for gay men there still is no prevention other than condoms, which seem less necessary as HIV seems less threatening.

Nationwide the current rate of infection has been reduced from 100,000 people a year to 40,000, largely because of safer sex habits and needle- exchange programs. But in San Francisco, at least, fear and safe habits are declining in tandem.

For gay San Franciscans of a certain age, Katz says, "the chance that your sex partner is HIV positive is 1 in 10 to 1 in 2." However, although the current cocktail of inhibitors is not a cure, "it looks and feels like one . . . If people you know are HIV positive and are going to the gym and going to work and look great, what kind of message does that send to you?"

The message is writ large in the fact that the behavioral changes of the late 1980s are not being sustained. Gay men are having two to three times more unsafe sexual partners. The decline of fear produces fatalism about the inevitability of unsafe sex.

So the public health message, aside from "there are problems with the medicines -- you could still die," becomes, for example, the encouragement of "assortative mixing" (encouraging HIV positive people who are averse to condoms to have sex only with other positives). But Katz recognizes that such messages are of limited utility when gay sex is fueled by substance abuse and Viagra.

Still, the good news is very good indeed: In this city AIDS is no longer, as it was 1990-96, the leading cause of death as measured by expected years of life lost.

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